Diuretic therapy is the mainstay of treatment for heart failure exacerbations but its optimal dosing strategy remains unclear. In 2011, the DOSE trial exhibited a trend toward improvement in patients’ global symptom assessments when utilizing a high-dose diuretic strategy, which used nearly 80mg intravenous furosemide three times daily in the first 72 hours on average. To improve heart failure outcomes and test the applicability of this trial to our population, we implemented the initial dose of 80mg intravenous furosemide three times daily for patients admitted through our emergency department. We hypothesized that standardizing high dose furosemide for all patient populations may lead to some negative inpatient outcomes.
Consecutive 334 patients admitted for acute systolic or diastolic heart failure were identified in an urban, academic medical center and reviewed from July 2014 to June 2015. Total diuretic dose was defined as total diuretics administered in the first 72 hours after hospitalization. Multivariable regression models with stepwise selection method were used to assess the statistical association between variables and inpatient outcomes including length of stay, worsening renal function, 30-day readmission rate, and mortality.
Higher total furosemide dose in first 72 hours was significantly associated with longer length of stay (Coefficient 0.0032, p= 0.000), higher reduction in GFR (Coefficient -0.00085, p= 0.000), higher grade of worsening renal function (OR 1.0013, CI 1.0006 – 1.0019, p= 0.000). Importantly, there was no association between total furosemide dose and 30-day readmission rate or inpatient mortality. Higher reduction in GFR was significantly associated with longer length of stay (Coefficient -11.2, p=0.000). History of stroke and history of heart failure admission in past twelve months were significantly associated with higher 30-day readmission rate (OR 2.4, CI 1.15 – 5.09, p=0.019 and OR 2.4, CI 1.32 – 4.53, p=0.004, respectively).
In patients admitted for acute heart failure exacerbation, higher diuretic dose in first 72 hours was associated with longer length of stay and worsening renal function in the setting of increasing initial diuretic dose in our patient population. Even though a high dose diuretic strategy is advantageous for reducing symptoms early per the DOSE trial, our data suggest that physicians should use clinical judgment, and that other variables may play a role in applying a high dose strategy to the appropriate patients.